I read with interest the recent article by Dr. Gordon Christensen ("Elective vs. Mandatory Dentistry," October JADA). I agree with his premise, but would like to respectfully disagree with some of his statements.
I don’t think all or nearly all knowledgeable dentists would agree about what is mandatory or elective. I believe this is determined by each doctor and how much disease he or she is willing to accept. The same can be said for patients. When we say, "You should brush more," and send them on their way, have we treated them to the best of our ability or accepted this level of disease?
For example, does gingivitis require "mandatory" treatment? Does periodontitis? If so, does a three-month recall constitute mandatory treatment? It is the standard of care but excluded by most insurance companies! Does frank caries require mandatory treatment if it doesn’t hurt and isn’t causing systemic problems? How does this differ from early periodontal disease or gingivitis? The same question applies for ditched margins or the edentulous case Dr. Christensen uses as an example.
Finally, what about occlusal disease? There is no question that abfractions, severe wear and anterior tooth destruction from over-closed bites is pathological and, in most cases, treatable, but many patients, dentists and certainly insurance companies find treating these things elective.
The reality is, people can and do live with these pathological conditions constantly. As I said earlier, it is simply a matter of how much disease we are willing to accept! I am often considered to be overtreating (certainly by the insurance companies) when I recommend eight-week recall intervals for some periodontal patients despite the fact that it is what is needed to control their (not some average patient’s) periodontal disease.
The same for recommending an indirect composite inlay or onlay when an amalgam would "do." Unfortunately, we have shot ourselves in the foot by accepting, in many cases, oral disease as "normal" and accepting the cheapest alternative as the standard.
I, and many others who have coached me, contend that nearly all dental treatment is elective. People have proven beyond a shadow of a doubt that they can live without teeth. It is simply a question of what people want. If they want the best we can offer, nearly every patient can have a truly healthy mouth.
The problem for me comes when it is the dentist and not the patient choosing (and worse yet, the insurance company) what level of disease to accept. Most patients are not given the option to have ideal treatment, and that is our profession’s downfall.
